Multicomputer data transferring and processing system

ABSTRACT

Healthcare is administered to members/enrollees of a healthcare plan according to objective quality standards. A patient population of eligible members/enrollees is identified and for each member/enrollee, medical information is aggregated via a web-based compilation of medical data from multiple sources that is continuously updated so as to provide an accurate, up-to-date and readily accessible compilation of a member/enrollee past diagnoses, healthcare history, medical procedures, medications and the like. Such member/enrollees are continuously tracked, on an individual basis, and monitored to ensure healthcare is delivered for a variety of specific medical conditions pursuant to objective health program quality criteria.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a divisional of U.S. patent application Ser.No. 13/715,852, filed Dec. 14, 2012, entitled METHODS FOR OPTIMIZINGMANAGED HEALTHCARE ADMINISTRATION AND ACHIEVING OBJECTIVE QUALITYSTANDARDS, which is a continuation of U.S. patent application Ser. No.13/712,776, filed Dec. 12, 2012, entitled METHODS FOR OPTIMIZING MANAGEDHEALTHCARE ADMINISTRATION AND ACHIEVING OBJECTIVE QUALITY STANDARDS, theteachings of all of which are incorporated herein by reference.

STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT

Not Applicable

BACKGROUND

In a managed care setting, whether it is for commercial or seniorproducts, health insurance is offered individually, through an employeror through Medicare. In all cases, the patient's coverage often changes.Whether it is a change in benefits or moving out of the service area,providers often move in and out of a patient's ecosystem, which thencauses disjointed and incomplete health information and assessment ofthe quality of care rendered. Along those lines, in our current state ofhealthcare, there is not enough incentive (funding) to measure everyhealth quality measure to ensure optimal healthcare is administered toeligible recipients. There are variations in the collection andreporting of data as well as the categories that are measured betweenprograms. For example, pay for performance programs tend to allowgreater flexibility in the ability to capture supplemental data thansome of the other programs but are far limited in the number of qualityoutcomes measured, especially for the high utilizing senior population.

With these varying programs, as well as many health plans introducingtheir own quality initiatives, it is almost impossible for providers tokeep track of the appropriate health maintenance programs for theirpatient population and much less insure that quality care is beingadministered. As a consequence, duplication and errors are morecommonplace, causing the quality of care to be negatively impacted.

Moreover, managed care is typically restricted to a specific servicearea and typically incorporates a referral and utilization managementprocess which thus further limits a continuum of care to beadministered. It has likewise not been enough to avoid hospitaladmissions and bend the cost curve. In such scenario, Pareto's Lawapplies: 20% of the population accounts for 80% of the costs. In orderto truly impact the cost curve, care coordination must take front andcenter, with an immediate focus on the high risk members.

Even though there are many tools in the marketplace, none understand theproblem and provide the means to a solution. The perfect tool needs tointerface with a range of healthcare data coming from different payors,Electronic Medical Records (EMR) providers, payment systems and so on soas to accomplish two objectives: 1) accurately diagnosing and trackingeach specific patient's medical condition and timely updating suchinformation so as to provide a continuously accurate picture of apatient's health; and 2) ensuring that each specific patient eligible toreceive healthcare benefits in a given program are administered suchthat the quality of care adheres to an objective, high-quality standardso that in all cases each patient receives quality care that iscommensurate with the accurately diagnosed condition. Unfortunately, nosuch systems currently exist.

BRIEF SUMMARY

The present invention specifically addresses and alleviates theabove-identified deficiencies in the art. Specifically, in a firstcomponent of the present invention, there is provided a comprehensive,readily-accessible assessment of each specific patient's health profilebased on aggregated member data from multiple data sources. Thecomprehensive patient data is compiled from many different sources,namely, electronic health records and electronic medical records(EHR/EMR), insurance claims/encounter data, clinical lab results, filledmedications, referrals, admissions, primary care medical recordsimmunization registries, specialist and hospitals reports, andinformation reported by Centers for Medicare & Medicaid Services (CMS),including both electronic and paper records. Such data is aggregated andstored on a storage medium at a central database and is presented to theproviders at the point of service to their members.

Based on the comprehensive data, patient information is gathered andpresented to healthcare providers to thus assist providers to makebetter clinical decisions based on available data. Such data aggregationhelps providers understand the member's medical condition better, andassists by ensuring all appropriate medical conditions are treated. Tothat end, such data is deployed to selectively administer healthcare tospecific patients in a patient population (i.e., members or enrollees ina given healthcare plan) in order to assist the providers to provide thehighest level of healthcare possible, while reducing theiradministrative burden by categorizing each of their patients into theappropriate quality programs.

To that end, the present invention uses patients' aggregated healthcareinformation to generate a population eligible for each of the qualitymeasures of a specific health quality program. In this regard, and as iswell-known in the art, numerous objective healthcare administrationquality standards have been set that will serve as the objectivecriteria against which the healthcare administration methods of thepresent invention are applied to the specific patients in the eligiblepatient population as warranted based upon the aggregated healthcare andcomprehensive patient data. Whether the health quality program isderived by the Centers for Medicare & Medicaid Services (CMS) such asthe Five-Star Quality Rating System, National Committee for QualityAssurance (NCQA) such as the Healthcare Effectiveness Data andInformation Set (HEDIS) Quality Measures, or Integrated HealthAssociation's (IHA) Healthcare Pay for Performance (P4P) program, thepresent invention assists in the effective management of such programsto identify quality gaps and triggers with its built-in workflowprocesses. Specifically, once the eligible population (denominator) hasbeen established, it calculates the set of patients that have fulfilledrequirements for the measures (numerator) as well as the ones that havenot met the criteria, also known as the non-compliant patients(numerator non-compliant or patients with “quality gaps”).

In response, the present invention summarizes the information in usablecategories by quality measurement programs, health plans, and providers.It is dynamic enough that a user can create summary reports based onone, two, or all of the categories to ultimately present the informationnecessary to affect improvement in quality measurement scores asdetermined by an objective health quality program.

In addition, the present invention provides a decisions support systemwith comprehensive patient information. Likewise, the systems andmethods are web-based, and users can access the patients' informationfrom anywhere the Internet is accessible through a secured loginprotocol. It can be integrated with any EHR/EMR application to provide acomplete history and overview of the patient condition to thus enablehealthcare providers to appropriately address any healthcare need thatmay arise.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other features and advantages of the various embodimentsdisclosed herein will be better understood with respect to the followingdescription and drawings, in which like numbers refer to like partsthroughout, and in which:

FIG. 1 is a schematic diagram of the computer/server architecture bywhich healthcare information, compiled from multiple sources, isaggregated for use in patient assessment pursuant to the methods of thepresent invention.

FIG. 1A is flow chart depicting the general steps for performing themethods of the present invention.

FIG. 2 is an exemplary screenshot summarizing information regarding aspecific patient population defined by eligible members/enrollees in ahealthcare program with review capabilities as to the healthcareprovided to patients within the population.

FIG. 3 is an exemplary screenshot providing risk adjusted factorcomparative analysis between health plans per each respective plan'sproviders and current year expenses versus previous year expenses.

FIG. 4 is an exemplary screenshot identifying and summarizingcomprehensive patient data, as well as objective health qualitymeasures, as measured against an objective, specific health qualityprogram, that are outstanding for an individual patient.

FIG. 5 is an exemplary screenshot displaying compiled informationdetailing claims, hospital admissions, lab results and medicationrefills, as well as the specific healthcare provider, designatedspecialty, diagnosis for which treatment was provided to a patient andthe date such services were rendered for a given patient within theeligible patient population.

FIG. 6 is an exemplary screenshot whereby diagnostic information for aspecific patient, as represented by a diagnostic code, may be addedand/or modified based on a review of available data and scanned medicalrecords.

FIG. 7 is an exemplary screenshot depicting how the methods of thepresent invention are operative to compile and generate data indicativeof the prevalence of one or more diseases/chronic health conditions in agiven patient population, as well as the trend in prevalence and costsassociated with treatment for a given condition.

FIG. 8 is a schematic view of the computer/server architecture for usein implementing the administration of healthcare pursuant to anestablished health quality program.

FIG. 9 is an exemplary screenshot summarizing specific objective qualitymeasures and how a given plan has achieved specific quality outcomes, asrepresented in a star-scale format.

FIG. 10 is an exemplary screenshot of a monthly trend report trackinghistorical compliance scores for each objective quality measure.

FIG. 11 is an exemplary “Boarding Pass” that provides a specific patientwith a list of healthcare objectives to be met so as to comply with agiven quality control measure.

FIG. 12 is an exemplary screenshot operative to enable informationspecific to a particular patient regarding specific quality measuresthat have been met or not met, and providing for supplemental data orexclusions that may apply to that patient for a given quality measure.

DETAILED DESCRIPTION

The detailed description set forth below is intended as a description ofthe presently preferred embodiment of the invention, and is not intendedto represent the only form in which the present invention may beimplemented or performed. The description sets forth the functions andsequences of steps for practicing the invention. It is to be understood,however, that the same or equivalent functions and sequences may beaccomplished by different embodiments and that they are also intended tobe encompassed within the scope of the invention.

Referring now to the drawings, and initially to FIG. 1A, there is shown,generally, a method 10 depicting the steps necessary to: 1) identify aspecific patient population of members/enrollees that are eligible toreceive healthcare and compiling and tracking all related healthcareinformation with each respective patient within such population; and 2)administer healthcare to each specific individual member/enrollee withinthe patient population according to a standardized measure of healthquality whereby the care and management of a specific disease,healthcare need and the like will be administered so that healthcare isprovided that complies with the standardized health quality measure.

Initially, the process 10 begins with step 20 of identifying a patientpopulation of specific members/enrollees eligible to receive healthcarepursuant to the methods for the present invention. Such step 20 may beaccomplished via a variety of conventional methods known in the artwhereby eligible patients are enrolled within a healthcare plan. Suchstep 20, may be accomplished, for example, via the use of applicationforms, medical screening and the like, coupled with one or more eligiblerequirements, such as base line health status, age, income and the like.

Once such patient population is identified in step 20, a comprehensivecompilation and aggregation of medical information concerning eachpatient within the patient population is derived from a multiplicity ofsources. In this regard, step 30 will involve aggregating patient datafrom a plurality of databases shown in FIG. 1, that are ultimatelycompiled and stored in computer readable form on a central database.Specifically, as shown in FIG. 1, the central database 200 will belinked via a telecommunications link to databases associated withmembership/enrollee information at 210, databases of the patient'sprevious insurance claims and encounters 220, pharmacy information 230,including the various medications that have been previously prescribedto the patient, dosage and other relevant information, laboratoryresults 240, hospital admissions 250, all pertinent data associated withtreatment/healthcare services rendered by Centers for Medicare Services(CMS) 260 and any and all information separately stored and accessibleconcerning prior authorization concerning healthcare services previouslyrendered to the patient.

As will be appreciated by those skilled in the art, the central database200 will thus serve as a comprehensive, readily accessible aggregationof patient data that serves as an up-to-date profile of a patient'shealth status and prior medical history. Such information may beaccessed by a remote computer 280 that may be linked to the centraldatabase via a web-based application to thus enable the user at 280 toaccess information on the central database 200 anywhere via theInternet. Along those lines, it is contemplated that access to thecentral database 200 via remote computer 280 will thus enable healthcareproviders to review such information readily, as well as update patientinformation at step 40 of FIG. 1A, whereby new diagnoses codes, updatedencounters, and other information depicted as 300 in FIG. 1, can beentered as part of the patient information stored on the database 200.Ultimately, a patient profile is created and stored on the centraldatabase 200 for each patient within the patient population. Eachpatient profile can thus be readily accessed and provides an assessmentof the patient's current health status.

Once the patient population has been defined and the health records ofeach individual created and updated in the aforementioned manner, astandard of care, preferably an objective standard of care, is providedin step 50 to serve as a basis by which healthcare is administered tothe patient population. With respect to the standardized criteria, it iscontemplated that any of a variety of known, well-recognized objectivecriteria of standardized health quality measures may be readilyreferenced and utilized in the practice of the present invention.Exemplary of such health quality standards include any of those known inthe art such as those derived by the Centers for Medicare and MedicaidServices (CMS) such as the five-star quality rating system; NationalCommittee for Quality Assurance (NCQA) standards including the HealthCare Effectiveness Data and Information Set (HEDIS) quality measures; orIntegrated Health Association's (IHA) Health Care Pay for Performance(P4) Program.

In use, and as depicted in FIG. 1A, the methods of the present inventionare operative to continuously monitor, update and compare each of thepatient member/enrollee profile information to the standardized healthquality measures chosen to be implemented as part of such methods, witheach patient continuously being assessed as to whether or not they arebeing treated in accordance with such standardized healthcare measuresper step 60. To that end, such administration of healthcare may take theform of the methods of Applicant's co-pending U.S. patent applicationSer. No. 13/712,758, filed Dec. 12, 2012 entitled METHODS FORADMINISTERING PREVENTATIVE HEALTHCARE TO A PATIENT POPULATION, theteachings of which are expressly incorporated herein by reference. Adecision is then made at step 70 as to whether or not each patient hasbeen adequately treated to meet the standardized quality of care setforth in step 50.

To the extent treatment has been adequately rendered consistent with thestandardized criteria, the method ends at step 80. Alternatively, to theextent quality measures have not been met, a further step 90 isperformed whereby the specific procedures and/or healthcare necessary tomeet the standardized health quality measure at step 50 are identified.Along those lines, such measures may take any of a variety of recognizedmedical conditions and diseases as compared with the recognizedtreatment and measures to be implemented to address the specificcondition, as set forth in the standardized criteria of step 50.

Thereafter, an assessment is made as to whether or not the deficientmeasures have been adequately addressed or resolved at step 100, inwhich case if so the process ends 110. To the extent such deficiencieshave not been addressed consistent with the objective criteria, suchdeficiencies are again identified by repeating step 90 and againevaluating at step 100 as to whether or not the objective criteria havebeen met until such time as adequate care has been rendered to a desiredpercentage of the patient population. Along these lines, it iscontemplated that providing at least 80% of the eligible patientpopulation with care consistent with the standardized health qualitystandards of step 50 will be a minimum benchmark. Attaining percentagesof 85%, 90% and 95% of eligible patients are optimal targets.

The present invention, through its web-based system of compiling,tracking and updating critical patient data from multiple sources, andcomparing the specific needs of each patient with criteria to be metpursuant to the standardized health quality measures, an exceptionallyeffective and efficient healthcare delivery system is thus defined thatnot only optimizes healthcare delivery but eliminates waste, preventsoutdated patient data from influencing critical healthcare conditions,and ensures that only the most appropriate healthcare is provided which,in turn, substantially conserves healthcare resources and numerous otherbenefits.

The present invention by which the aforementioned methods are achievedprovide other ancillary benefits that are further effective indocumenting healthcare administration trends, problem areas, waste andother specific issues related to healthcare administration so as tomaximize efficient healthcare administration. As discussed above variousdatabases and medical information from which the present invention drawsupon (See FIG. 1) aggregate patient information in real time so as toprovide any healthcare provider at any point in time the most up to dateinformation possible regarding the healthcare information of a givenindividual for use in steps 30 and 40 of FIG. 1A. FIG. 1 furtherillustrates how the application and web servers are structured fordata-transfer and retrieval. In this respect, the plurality of databasesare tied to a central database so as to relay information on aconstantly updated central database. Such databases preferably include adedicated database related to each member or enrollee in a given healthmanagement plan; the specific claims and encounters each member has hadrelated to physician visits or instances where healthcare has beenprovided; pharmacy data, including prescription history and the like, adatabase of all lab work associated with each member, including allrelevant clinical findings, a hospital admissions database, a databaseassociated with each and every center for Medicare/Medicaid service hasbeen provided where applicable for each member/enrollee, and lastly adatabase associated with any and all authorization associated withdecisions as to approval or denial of a given procedure, treatment, etc.had been previously determined. Moreover, although not shown, a furtherdatabase may include any and all electronic medical records/electronichealthcare records (EMR/EHR) that may be associated with a patient thatmay be further made accessible to provide as accurate and thoroughinformation as possible given the health condition of a givenmember/enrollee.

In one exemplary embodiment, there is shown in Table 1 below the varioustypes of data that are continuously tracked by the central database,exemplary sources from where the data is derived, and the frequency bywhich such information is updated (i.e., per step 40 in FIG. 1A). Aswill be appreciated by those skilled in the art, such medical data asreflected in Table 1 can and will be fluid in nature and constantlychanging. Moreover, although the frequency of the rate at which thisinformation is updated may vary, it is believed that Table 1 reflectsthe most optimal timing (i.e., daily, monthly or as required asindicated respectively) by which such information should be updated.

TABLE 1 Exemplary Information # Data Type Source of Data ExtractedFrequency 1 Claims/ EZ-CAP ® Claims at the Daily Encounters ClaimsModule member level, aggregate paid amounts, summary of payments atprovider and vendor levels 2 Membership EZ- CAP ® Member details, DailyEligibility summary of Module eligibility data at vendor and providerlevels 3 Providers EZ- CAP ® Provider details Daily Provider Module 4Utilization EZ- CAP ® Admissions by Daily Case level of care, Managementlength of stay EZ- CAP ® and other Authentication case details All thereferral with status 5 Lab Results Quest/LabCorp Lab Results Monthly 6Pharmacy Health Plans/ Medication refills Monthly Data PBM with dosageand other details 7 MMR/MOR Health Plans/ Member Monthly (MonthlyPrimary Benefit demographics, Membership Managers (PBM RAF score andReport/Medical accepted HCC by Overpayment CMS Report) 8 System/ ManualDiagnosis As and Support Hierarchical when Condition required Categories(HCC) mapping, disease group mapping etc.

With respect to the hardware necessary to implement the foregoingtransfer of data between the central database and the various databasesconnected therewith, such may be accomplished by a variety of computersystems and servers well-known in the art. Presently, it is believedthat Microsoft SQL 2005/2008 servers are exemplary of such serversthrough which the methods of the present invention may be accomplished.Also, it will be readily understood by those skilled in the art that theexemplary sources of data set forth in Table 1 will typically representwell-known and extensively utilized healthcare industry software anddatabases practiced in the art. For example, the information derivedfrom claims/encounters, membership, providers and utilization can bederived from any of a variety of health plan administration software,including the EZ- CAP® software produced by MZI HealthCare, LLC ofValencia, Calif. that is operative to manage health benefitadministration, automation of claims and other healthcare transactions,and oversee financial and medical management. Similarly, lab results canbe readily accessed through well-known diagnostic testing providers suchas LabCorp Laboratory Corporation of America and Quest Diagnostics.Other sources of data that can be accessed for providing comprehensivepatient health information will further be readily appreciated by thoseskilled in the art.

Given the foregoing architecture and the various databases to which thecentral database is coupled, it will be understood that a hierarchy ofaccess will be implemented to thus maintain the security and integrityof the various healthcare information stored and accessible in suchdatabase, as well as to restrict access to only those having a need tosuch information.

Along those lines, at present it is contemplated that access to thedatabase supports specific categories of users, namely, themember/enrollee, healthcare provider, management and coder/auditor(i.e., quality control specialists certified to review deficiencies incapturing diagnoses and to capture diagnoses after reviewing the medicalrecords/charts from primary care providers, specialists offices andhospitals).

Provider login is designed to deliver the potential condition reviewsand reports at the point of service with the member. Provider can reviewa one-page member summary information for the member assigned to themwhich includes member demographic, reviews for potential condition,diagnosis and procedures captured in the claims and encounter data, labresults and pharmacy data along with risk scores and currenthierarchical condition categories (HCCs) for the member provider has theability to “drill down” and selectively target and isolate theinformation to find more details as well as the ability to view scannedcopies of the medical records from primary care and/or specialistoffices and hospitals.

Management login is designed to present the reports which helpsmanagement team to identify members with certain conditions orcomorbidities, and to identify opportunities to improve the risk score.Management users are able to see updated reports such as the comparativerisk scores by health plan and by provider, list of members withoutstanding reviews by provider and by review category and many morewhich assists the management team to focus on the specific area wherethey can exert resources the most effective and efficient way.

Coder login is designed for certified coders and supervisors to reviewthe deficiencies in capturing diagnoses and to capture diagnoses afterreviewing the medical records/charts from primary care providers,specialist offices, and hospitals.

To begin utilization of the computer systems and methods of the presentinvention, it is understood that a login process will occur for any ofthe aforementioned entities after which the applicable user will bedirected to a dashboard/homepage. A Dashboard/Home page, as shown inFIG. 2, has summary information on overall membership including activeand termed members, number of total reviews, completed reviews andoutstanding reviews. The central database allows user to switch betweenthe years to look at the data either for the current year or previousyear. Based on the level of access, users will be able to seeinformation for assigned members (Provider login) or all the members(Management login). Management login also has an ability to filter theall the reports for a particular provider to mimic a provider'sviewpoint. The left side of the home page as shown in FIG. 2 has menu tonavigate the application. Each section has one or more sub-sections ordrilldown reports.

Advantageously, the computer/server architecture enables three reportsand related drilldown information to be readily derived down to thePrimary Care Physician (PCP)/member level. The items, available underthis menu are:

-   -   Risk Adjusted Factor (RAF): Revenue Current Year (CY) vs.        Revenue Previous Year (PY): This report compares two year data        by health plan. This report serves multiple purposes, to        identify health plans which are attracting sicker membership        compared to other health plans which helps management to        identify any data deficiency for a particular health plan or        opportunity to optimize coding effort.    -   RAF: Expense Current Year (CY) vs. Expense Previous Year (PY):        As shown in FIG. 3, this report compares CY and PY RAF score by        health plan for the CY active or termed members which give users        an overall RAF score for the same membership between two years.    -   Open Review/Encounter PMPY: This report gives brief overview of        current enrollment, RAF scores (demo and risk) and comparison        between CY and PY by health plan.

Similar to the Review by Health Plan section, the present inventionfurther provides the following three reports by PCP and relateddrilldown information to the member level to thus enable year-to-yearrevenue and expense comparisons.

-   -   RAF: Revenue Current Year (CY) vs. Revenue Previous Year (PY)    -   RAF: Expense Current Year (CY) vs. Expense Previous Year (PY)    -   Open Review/Encounter PMPY

Using these reports, management will be able to identify Primary CarePhysicians (PCPs) who may have deficiency in coding. Users have theability to print multiple member summary pages from the list of membersassigned to a particular provider. Users can also request medicalrecords and export data to Excel for easier manipulation of data. Inaddition, users have the ability to review at the member level byselecting member id from reports available under Review by Health Planand Review by PCP.

As shown in FIG. 4, a member summary page, derived in conjunction withstep 30 of method 10 in FIG. 1A, provides comprehensive informationabout member demographics and health conditions which include:

-   -   Member demographic information    -   Outstanding HEDIS measures    -   Health status indicator (Primary Care Provider (PCP) visit, ESRD        status, Hospice, etc.)    -   Current year HCCs    -   Potential health condition    -   Three year history of HCC/diagnosis    -   Three year history of procedures    -   Access to scanned medical records    -   Medication prescription/refills for the last six months    -   Lab results for the last twelve months (GFR, CR, Cholesterol,        HgbA1C, Microalbumin)    -   Clinician comments

Users can review further detail for claims, admissions, lab results,medication refills in Member Data tab as shown in FIG. 5. The presentinvention also reports information on how potential health condition isderived under Reviews tab as shown. Member Info tab allows users torequest medical records (generate letter) from the PCP. Clinicians andcoders have the ability to make comments/notes after reviewing healthinformation and medical records available under the Member Summary Page.User also has ability to see history of all thereferrals/authorizations, including referrals status of the selectedmember.

As shown in FIG. 6, Coders (i.e., individuals who review and updatepatient diagnoses) have the ability to add new encounter/diagnosis basedon review of available data and scanned medical records. The presentinvention has the ability to track the page number from where the coderis coding the diagnoses, which helps the organization provideappropriate back-ups during CMS/Health Plans audit(s). Using multipleedits, the president invention prevents the coder from enteringinappropriate diagnoses. If any deficiency exists in the medical charts,the Coder has the ability to add comments while reviewing the medicalcharts, which in turn gives feedback to providers on improving theirdeficiencies.

Based on the severity and chronic nature of certain medical conditionsthat require the most medical attention and utilization of healthcareresources, the systems and methods of the present invention specificallytake into account numerous categories that are assigned to specificmembers/enrollees where applicable, as shown in Table 2 below.Specifically, there are currently eighteen different medical conditionreview categories that are tracked and generated by the central databaseusing member's claims/encounters, admissions, lab results, medicationrefills and MMR/MOR data (again, as part of compiling data in connectionwith steps 30 and 40 of method 10 of FIG. 1A).

TABLE 2  1. Non-Submittable  2. ESRD Co-Morbidities  3. High Cost  4.Pharmacy  5. Chronic Condition  6. Correct Coding  7. Hierarchical  8.Further Specificity  9. Transplant 10. Malnutrition 11. DME 12.Behavioral Health 13. Cardiovascular 14. Diabetic Co-Morbidity 15. Renal16. Pulmonary 17. Clinician Review 18. Prevalence

The present invention additionally allows users to send out surveys toverify the status of working aged members and includes a workflow tomake sure members have minimum of one PCP visit during each calendaryear so that member's primary care physician can review the member'shealth condition on an annual basis.

Still further, the present invention is operative to compare a givengroup's claims/encounter data with CMS published fee for service (FFS)data to identify deficiencies in coding. Also this report helps identifymanagement to review any potential over coding for a particular HCC. Asshown in FIG. 7, the database is operative to compare data at the HCClevel and allows users to assess healthcare delivery down to the PCP andmember level.

As disclosed above, the present invention initially tracks, identifiesand aggregates medical information that correctly and thoroughlydocuments the health history of each member/enrollee in as comprehensivea manner as possible that is further updated on a frequent basis.Because the systems and methods of the present invention socomprehensibly capture and track the medical condition and history oftreatment associated with each specific member/enrollee, the presentinvention is further operative to ensure that the healthcare that isdelivered is maintained at whatever level is necessary to meet a givenobjective criteria of healthcare delivery, as discussed above and morefully below. Advantageously, because the present invention is completelyweb-based, it allows access to the application from virtually anywherethe user has Internet access and without the need to deploy installationsoftware. Its interface capabilities with Electronic Health Record (HER)systems also provide easy access at the point of care.

To that end, the aforementioned aggregated data is designed to deliverall the capabilities of the application to the healthcare provider forits patient population. This in turn will allow access, either viaweb-based application access or via EHR interface link, to theprovider's patients' quality measurement status preferably at the pointof care, as per step 60 of FIG. 1A to thus compare the treatmentrendered relative the standard criteria.

To determine the optimal healthcare to be provided per steps 70 and 100of FIG. 1A (i.e., per an objective set of quality measures referred toabove), the methods of the present invention likewise deploy acomputer/server system to track and implement healthcare measures.Similar to the architecture discussed above with respect to identifying,tracking and aggregating medical data associated with eachmember/enrollee associated with a given plan, a related architecture isdeployed for use in ensuring that the healthcare that is administered tothe patient population adheres to an objective set of criteriarecognized as meeting each specific patient's healthcare needs. In thisregard, there is provided a central database coupled to a plurality ofdatabases whereby the central database aggregates date for use inensuring that healthcare is administered optimally pursuant to objectivecriteria, as shown in FIG. 8.

The source data for calculating and categorizing the quality measuresare membership, claims and encounter data from the claim processingsystem, Electronic Health Records (EMR) data, clinical laboratory data,pharmacy data, disease and immunization registry, and other source data.The supplemental data that are captured in central databases can beimported back to the claim processing system via EDI.

As shown in Table 3 below, similar to Table 1, there is provided varioustypes of data, the source from which the data is obtained, the type ofdata and the frequency by which the data is updated for use in ensuringthat healthcare is provided according to quality standards per themethods and systems of the present invention.

As will be understood, such healthcare information may be compiledutilizing existing technology and computer and server hardware. It islikewise contemplated, as discussed above, that a variety of sources arereadily known and understood in the art that will provide the soughtafter data and further, that other sources of data relevant to thepatient's receipt of medical treatment may be accessed and integrated tosupplement the methods disclosed herein.

TABLE 3 Exemplary Information # Data Type Source of Data ExtractedFrequency 1 Claims/ EZ- CAP ® Claims/ Bi-Weekly Encounters Claims ModuleEncounters at procedure level 2 Membership EZ- CAP ® Member detailsBi-Weekly Eligibility Module 3 Providers EZ- CAP ® Provider detailsBi-Weekly Provider Module 4 Utilization EZ- CAP ® Admissions byBi-Weekly Case level of care Management length of stay 5 Lab Results LabVendors Clinical Lab Monthly (Quest/LabCorp) Results 6 Pharmacy HealthPlans/ Medication refills Monthly Data PBM with dosage and other details7 Disease Health Plans/ Member Health Monthly Registry GovernmentRecords 8 Immunization Health Plans/ Member Health Bi-Weekly RegistryGovernment Records 9 HER/EMR NextGen Clinical data Bi-Weekly

There are several key functionalities that are derived via suchaggregated data that ensures the delivery of high quality healthcare. Toidentify what measures need to be implemented, the present inventionprovides a simple, one page outstanding list that can be used by theproviders as well as the patients. When dealing with supplemental datacapture (i.e., when a measure has been achieved, etc.), not only does itincorporate an intuitive method of capturing the data but also providesmedical record upload capability which is essential during reportingaudit processes. In cases when removing patients from a quality measureis necessary, the present invention further provides an easy exclusionprocess which is approved by each quality measurement program.

The Summary by Measures page, as shown in FIG. 9, provides an overallsummary for all quality measures, health plans, and in the case formanagement login, all providers. This is the starting point indetermining the overall view of current compliance rates against thebenchmarks.

The summary report breaks down the patient population into the line ofbusiness, commercial and senior, and further into major categories asdefined by the quality measurement programs. It displays the number ofpatients that are part of the eligible population as well as the oneswho are compliant on the quality measures and the ones that are notcompliant. The eligible population and the non-compliant patient listscan be generated for each measure by clicking on the respective linksfor each measure. It also identifies the number of patients that need tobe compliant in order to reach the benchmark. For the measures that arepart of the CMS Star Ratings program, for example, it also displays thenumber of stars based on the compliance rate.

As will be appreciated by those skilled in the art, the summary reporthas very flexible and powerful filtering capabilities. The drop-downlists allow the users to filter by quality measure type, health plan,and providers, or even any combination of all three criteria, viamethods well known in the art.

With respect to how each member of the population is actually cared for,the present invention first identifies all of those eligible fortreatment and to whom the objective quality standards are measured. Thisincludes each member's demographics as well as the name of their primarycare provider. As the members' eligibility changes on a monthly basis,so does the eligible population. As the denominator of a measurechanges, the compliance achievement scores are also affected. Bydisplaying the details of the eligible population, the focus of theirefforts can be limited to the member population that is currentlyenrolled in the quality programs.

Since the summary by measures report displays the number of patientsthat need to qualify for the measure to meet or exceed benchmarks, theNon-Compliant List of member/enrollees, also known as the “care gap”report, provides a list of “To Do” task list to the providers and themanagement team.

The Non-Compliant List provides a complete list of all patients thathave not fulfilled the necessary requirements for a given qualitymeasure. This list, which displays the members' demographics as well asthe name of their primary care provider, is very valuable as it is usedfor many outreach efforts to encourage the patients to perform theirpreventive care screenings and any disease specific tests such as HgA1Cand LDL cholesterol screening as well as breast, cervical and colorectalcancer screening tests.

As an additional feature, there is provided the member search functionthat can display more than just the list of patients. In addition to themember ID, name, date of birth, and their primary care provider, itdisplays the number of outstanding measures that the patient has notfulfilled. This provides a quick and easy way to determine whether thepatient is in need of any preventive or disease specific qualitymeasures and can alert the nurses, medical assistants, and providers ofthis fact before a given patient even enters the exam room.

There are also two additional set of information on the member searchpage which provides a link to the list of outstanding measures via the“Boarding Pass” which can be provided to the patients. In this regard,just as a boarding pass for an airline industry provides pertinent setof information such as where and when to board and where to sit, thepresent invention is operative to generate a “Boarding Pass.” SuchBoarding Pass provides the patients the list of what to do, as shown onFIG. 11.

The Boarding Pass provides member demographic information along with allrecommended quality and preventive care services that were generated bytheir quality measurement program. This example shows that this patientrequires function status assessment, glaucoma eye exam by anoptometrist, influenza vaccination for the upcoming flu season, and amedication review. The boarding pass also provides instructions to thepatients that if they have and any of these services performed elsewhereduring the current year to bring copies of the reports so that they canbe captured in the present invention and to prevent any repeat ofunnecessary tests.

This can empower the patient to ensure they are getting all the neededcare from their providers and health delivery networks. If the patienthas already had the quality measure for which it is displaying asnon-compliant, due to possible lag in data refresh or any records thatwere not captured electronically, the healthcare provider or their staffmember can add the supplemental data or exclude a member from a specificmeasure for any acceptable reason.

In order to track the overall quality measures as provided by a givenprovider to its patient population, a Monthly Trend report, as shown inFIG. 10, can be generated that keeps track of historical compliancescores for each quality measure exactly in the same format as theSummary by Measures report. This historical data can be used todetermine whether certain outreach programs were more successful thanothers and also determine if there are any cyclical patterns to manage.Indeed, virtually every aspect of healthcare provided to the eligiblemembers of the patient population can readily be assessed for complianceand further, may be adjudged against a benchmark standard.

With respect to the latter, the methods of the present invention areoperative to determine the effectiveness of healthcare administration bymeasuring against all relevant patients eligible to receive healthcarewithin the patient population have received care according to anobjective, standardized metric and measuring trends in that regard. Inthis respect, the methods of the present invention are operative toidentify healthcare administration trends amongst the patients withinthe patient population, which can include: the number of emergency roomencounters, whether ending in a non-admission or an admission; thenumber of urgent care encounters; the number of hospital admissions perthousand that were not authorized in advance; the number ofnon-prior-authorized hospital admissions; the number ofnon-prior-authorized admissions per thousand transferred from otherfacilities; the length of stay of patients admitted to a hospital, bothaverage and median; the number of office visits, home visits and thelike provided by healthcare providers to specific patients within thepatient population; and the percent of active members/enrollees withinthe patient population with updated and complete care plans.

Measurements of each such categories, plus numerous others that will bereadily appreciated by those skilled in the art, can be made weekly,monthly, quarterly, semi-annually and annually to identify not onlythose patients within the patient population that have receivedhealthcare consist with an objective standard of care (CMS five-starquality rating system; NCQA; HEDIS; and/or IHA P4 Program), but how suchhealthcare is administered over time and how healthcare can beadministered so as to decrease high-cost care, such as emergency roomvisits, hospital admissions, prolonged hospital admissions, and thelike.

As a consequence, all eligible members/enrollees within the patientpopulation can be assessed not only in the individual capacity, but as agroup as well. Advantageously, the methods of the present invention thusare applicable to not only health plans that treat individuals on a feefor service basis, but also through health maintenance organizations(HMOs) that are operative to allocate a limited number of resources to apatient population. The present invention is further applicable to trackand administer care according to such objective standards for as long asthe patient remains eligible or enrolled within a specific plan.

To make corrections, deletions and/or additions or may be required instep 100 of FIG. 1A, an Add Supplement Data and Exclusions function, anexample depicted in FIG. 12, is provided that allows the users to verifythe member demographics before entering any data. Once the correctmember record has been selected, the list of outstanding qualitymeasures is displayed with and “x” next to the measure. The measureswhere they are compliant will also appear but in green color with acheck mark next to the name indicating that it has been fulfilled.

After selecting the provider that provided the service, the users areable to enter the list of procedure, diagnosis and other event codesthat will trigger a compliant value along with the date of service andthe page of the scanned medical record where the data is indicated. Thedata entered is then verified by the application and if it meets all thecriteria, it will convert the outstanding measure with the red “x” to acompliant green check mark.

If the patient has a valid medical reason to be excluded for a qualitymeasure, such as a bilateral mastectomy for the breast cancer screeningmeasure, the qualified exclusion reason can be selected along with thedate of service and the supporting medical records. By virtue of suchmechanism, the determination is ultimately made as to whether or not agiven patient has ultimately been provided the level care commensuratewith a given quality measure, and if so, whether the patient's conditionhas been adequately addressed according to objective standards.Alternatively, such mechanism provides a continuing/persisting conditionfor a particular patient that warrants continued care pursuant to theobjective quality measures provided for a given plan. Still further,such mechanism enables the methods of the present invention, and inparticular steps 70 and 90 of FIG. 1A, to be terminated to the extent agiven quality measure is no longer needed to address a particularcondition, the patient's condition is addressed and/or the patient is nolonger eligible or some other event occurs whereby a given measure is nolonger applicable for a given patient.

In all circumstances, the present invention thus allows for not onlycontinuous tracking and updating of medical information to alwaysprovide the most up-to-date picture of the health profile of everymember/enrollee of a patient population, but further that objectivelyhigh standards of quality care are administered to each member untilsuch time as such measure is adequately addressed. Per the general stepsprovided in FIG. 1A, and as discussed more fully above with respect tothe various types of data generated through the methods of the presentinvention and the benefits derived therefrom, optimal healthcare can bedelivered that minimizes waste and reliance on potentially inaccurateinformation in addressing a patient population's healthcare needs.

The above description is given by way of example, and not limitation.Given the above disclosure, one skilled in the art could devisevariations that are within the scope and spirit of the inventiondisclosed herein, including various ways of aggregating medical dataconcerning a plurality of patients for multiple sources of data that isoperative to achieve an accurate diagnosis for each patient within apatient population and thereafter administer healthcare to deliverquality according to a specific health quality program that ensuresadequate care commensurate with the specific health conditions of eachpatient within the patient population is adequately administered.Further, the various features of the embodiments disclosed herein can beused alone, or in varying combinations with each other and are notintended to be limited to the specific combination described herein.Thus, the scope of the claims is not to be limited by the illustratedembodiments.

What is claimed is:
 1. A system, comprising: a plurality of servers,each of the plurality of servers corresponding to, exclusively, aplurality of individuals in a plurality of populations; a plurality ofcentral databases stored on the plurality of servers, having ahierarchical access control based on a category of user, the category ofuser being selected from the group consisting of member/enrollee,provider, management, coder, and auditor, each of the plurality ofdatabases dedicated to store information in records corresponding to oneof the plurality of individuals in one of the plurality of populations,and structured to filter out all incoming updates to the centraldatabases except those corresponding to one of the plurality ofindividuals; a computer running a plurality of applications, including aprogram for creating an individual profile, wherein the individualprofile for each of the plurality of individuals is stored in thecentral database; and a plurality of graphical user interfacesdynamically created by the program for viewing information from thecentral database and providing users with a capability to deriveinformation at a specified level; wherein a first graphical userinterface of the plurality of graphical user interfaces displays adashboard for displaying information on the patient population withreview capabilities as to services provided to individuals within one ofthe plurality of populations, wherein the dashboard includes anavigation menu with a plurality of navigation elements, the pluralityof navigation elements including Summary, Review by Plan, Review By PCP,Review by Category, Evaluations, Prevalence, Record Upload, and ReportsLibrary, wherein, under Review by Plan, a plurality of reports by PCPare selectable; wherein a second graphical user interface of theplurality of graphical user interfaces displays information providingRAF comparative analysis by plan for the CY active or termed members toprovide users an overall RAF score for the same membership between twoyears; wherein a third graphical user interface of the plurality ofgraphical user interfaces displays a member summary page; wherein afourth graphical user interface of the plurality of graphical userinterfaces displays information on claims, medication refills, provider,designated specialty of said provider, and date of services rendered;wherein a fifth graphical user interface of the plurality of graphicaluser interfaces displays information for an individual, as representedby a code, wherein the code may be added or modified based on a reviewof information, retrievable from the central database, associated withthe individual; wherein a sixth graphical user interface of theplurality of graphical user interfaces displays information on objectivequality measures as represented in a CMS star ratings program format;wherein a seventh graphical user interface of the plurality of graphicaluser displays information of a monthly trend report tracking historicalcompliance scores for each objective quality measure; and wherein aneighth graphical user interface of the plurality of graphical userinterfaces displays information specific to a patient of the patientpopulation regarding specific quality measures that have been met or notmet, and providing for supplemental data or exclusions that may apply tosaid patient for the specific quality measure.